Pancreatic cancer accounts for over 28,000 deaths a year in the United States. Since incidence rates and outcomes in a rural academic hospital setting have not previously been reported, we reviewed all patient records at Ruby Memorial Hospital in Morgantown from 1/90 to 12/99. Our study revealed 32,231 cancer patients during this time, of which 152 (0.5 percent) were diagnosed with pancreatic cancer. Only 32 (21.2 percent) patients had resectable tumors at time of diagnosis. The mean age of these patients was 67 years (range 34-83 years) and only 36 percent of operable patients were male. The majority of tumors (26 or 81 percent) were found in the pancreatic head, and 97 percent of the tumors were adenocarcinomas. Only three patients (9.3 percent) had well-differentiated tumors, with poorly and moderately differentiated histologies making up 40 percent and 50 percent, respectively. Operations performed included pancreaticoduodenectomy in 26 patients, total pancreatectomy in four patients, and distal pancreatectomy in two patients. There was only one perioperative death (3.1 percent). A total of 75 percent of the of the group underwent postoperative chemotherapy, mostly with fluorouracil-based monotherapy. Postoperative survival rate was 47 percent at one year, 25 percent at two years, and 9.6 percent at three years. No survival advantage was demonstrable in adjuvant treated patients. Our results show for the first time that pancreatic cancer is managed well in a rural hospital setting with equivalent short and long-term outcomes. The social and economic advantages of local patient care are supported by these results and warrant further study.